STUDY OF PPPs for EmoC under the JSY

1. STUDY OF PPPs for EmoC under the JSY A rapid assessment in a selected district of Maharashtra Conducted by Foundation for Research in Community Health, Pune Investigators:Dr. Bharat Randive Dr. Sarika Chaturvedi

3. PPP for EmOC in JSY of NRHM • Subsidisation of cost for management of obstetric complications and for CS • Hiring private / public specialist • Rs.1500 as specialist charges • Free EmoC in public facilities • JSY Eligible clients (Maharashtra)- • BPL, SC, ST • Over 19 years • Upto 2 live births

4. OBJECTIVES- To understand 1. Design of PPPs in Ahmednagar district (partner selection / contract mechanisms, performance measurement / facility accreditation processes / monitoring) 2. Execution of PPPs Experiences in implementing / using the scheme (Referral & transport / cost & consequences / financial provision for PPPs) 3. Perceptions of providers and users about PPPs for EmOC

5. Ahmednagar district health system Best SIS score Moderate performance Source – Health for Millions oct 07- jan 08 (IIPS Mumbai)

6. STUDY AREA • Ahmednagar district in western Maharashtra • MMR <2 for 1000 live births • SC-12.39% • ST-7.2% • 96 PHCs ,23 CHCs, 1 District Hospital • Mushrooming of private hospitals

7. SAMPLE SIZE 5 /14 blocks selected randomly 2 PHCs/ block selected randomly 2 beneficiaries/block selected randomly Respondents: Implementers- DHO, THO, MO/ANM (16) Beneficiaries (10) Non beneficiaries (8) Private EmOC providers ( 3)

8. DATA COLLECTION AND PROCESSING • Semi structured interviews, • Focus group discussions • Data for deliveries during June 07 to Oct 08 • Thematic analysis

9. CONSENT

10. LIVING CONDITIONS

11. PROBING

12. .. VENTILATING…

13. FINDINGS

14. Implementation of PPP • No contracting-in of private specialists • No empanelment/accreditation of private facilities • Private providers not approached for PPP, vaguely aware through patients • Thus NO PPPs in place

15. … Implementation of PPP • Benefit only to C- section, not to other obstetric complications Thus, 2/3 rd women in need of EmOC barred from eligibility • Rs. 1500 utilised as subsidy for C- section Cash assistance rather than service provision

16. …Financial provision • Rs.1500 paid as assistance post CS to women/doctor or either • Provision unattractive for hiring obstetrician, prevailing charges above Rs. 3000 • Inadequate public infrastructure for EmOC provision by hiring specialists

17. Financial assistance & Consequences • Average expenses incurred by women Rs. 15,000 (range 10,000 to 30,000) • Assistance received under PPP Rs 1500 • Thus, assistance Grossly Insufficient “enough only for pharmacy bills”- beneficiary 1 • Delay in disbursement - On avg recd 3 mths after delivery • Indebtedness - pvt. loans @ 60%pa

18. Proportion of JSY assistance to CS charges paid by women

19. .. Referrals • No referral chains, no referral slips • Women mostly approaching private facilities directly • Women's experiences • Difficulties in arranging transport “ ..We walked to the highway asking for lift..” -3 pm, “…reached the civil hospital- 8 pm”- Nonbeneficiary 2 Reached civil hospital at 40 Kms almost 5 hrs after diagnosis of obstructed labour

20. ..Transport provision • Women unaware of provision for transport facility for EmOC • Women experiences • Transport facilities not provided by PHCs • Average spending of Rs.600 for transport • Providers views • Varying provisions across blocks: Rs250/ Rs.500/ • Cashless arrangements • Reimbursement from sub centre strengthening funds

21. Reasons for non-utilisation and denials • Women unaware of provision for EmOC- no micro birth planning • Service area constraints- deliveries mostly at maternal homes • Difficulties in producing required documents in time - ? 7 days of delivery • Varying conditions for accessing the scheme- eg. registration before 12 wks, BPL survey rounds

22. HMIS data at district office about JSY: April -September ‘08

23. Findings- Views • Useful only for cities, not for rural areas “calling a doctor from town is equally good as taking the patient to the town”-District official • Services rather than cash subsidy “..provide the facility instead of the money… we poor do not have the money at that time to pay for the hospital, what if the government gives us the aid later on….” - Beneficiary 2 • Difficulties in implementation – • frequent changes in guidelines, • time and documents criteria, • funds flow issues

24. CONCLUSIONS…too little, too late • No PPPs for EmOC under JSY in study district • Inadequate financial provision for hiring specialists • Subsidy mechanism minimally influences out of pocket payments for EmOC services • Scheme implemented is exclusive • Infrastructural inadequacies, low motivation - barriers to implementation of PPPs

25. Causes of maternal deaths addressed under PPP

26. RECOMMENDATIONS • Emphasis on micro-birth planning- Ensure birth preparedness and complication readiness • Contracting-in / out rather than cost subsidisation & onus of negotiating charges should not be on the woman • Scheme should include all life threatening complications of pregnancy • Charges for hiring specialists should be based on area specific competitive rates • Capacity building for management of PPPs

27. ……Too far to go…. THANK YOU! Dr.Sarika Chaturvedi Dr.Bharat Randive